The goal of any oculoplastic procedure is to correct the underlying physical abnormality while achieving excellent functional and aesthetic outcomes. This requires meticulous preoperative planning, prudent placement of incisions, careful dissection along existing anatomic planes, conservative use of electrocautery, and appropriate closure of surgical wounds. It is helpful to review commonly used suture types and basic wound closure techniques that form the primary surgical foundation of ophthalmic plastic and reconstructive surgery.

Although handling eyelid tissue appears to be a simple task, it can be frustrating without the implementation of proper surgical technique or the use of appropriate instrumentation. In general, toothed instruments and retractors are best suited for manipulating and positioning tissues. Although 0.5 mm forceps are appropriate when handling the more delicate pretarsal or marginal skin, larger forceps, such as toothed Adson forceps, are useful for manipulating the thicker skin of the brow, cheek, and preseptal components of the eyelid. When assertive tissue placement or tension is required, larger forceps are again preferred because thinner forceps can lacerate the skin. Nontoothed forceps are rarely used in oculoplastic surgery because the pressure required to manipulate tissues with such instruments can introduce significant and unwanted crush injury.

Suture needles are designed to penetrate tissue with minimal resistance, carry the suture material through tissue with minimal trauma, and maintain its shape while being repeatedly passed through tissue. Each needle has three components: the attachment end, the body, and the point (Figure 1.1A). Needle size is measured in millimeters from the attachment end to the needle tip and usually corresponds to the diameter of the suture material. In general, the thicker the tissue and the greater the tension across the wound, the larger the size of suture necessary to pass through tissue and appose wound edges.

Needle shapes vary, with three-eighths circle and one-half circle being the most commonly used (Figure 1.1B). Three-eighths circle needles are typically used for most wound closures in oculofacial plastic surgery, but one-half circle needles are well suited for suturing in tight spaces, such as when securing a lateral tarsal strip to the periosteum of the lateral orbital rim.

The needle point itself determines how well the needle penetrates and passes through the tissue of interest (Figure 1.1C). Types of needle points include conventional cutting, reverse cutting, taper, and spatula. Cutting and spatula needles actually cut through tissue, whereas taper needles only push through tissue. A taper needle comes to a sharp point without a cutting edge and is therefore used to suture delicate tissues, such as the thin conjunctiva of the elderly. In oculoplastic surgery, cutting needles, in particular, reverse cutting needles, are most frequently used. When viewed on end, a reverse cutting needle appears as a triangle pointed downward, with its cutting edge on the outer curvature of the needle, whereas a conventional cutting needle looks like a triangle pointed upward, with its cutting edge on the inner curvature of the needle. Owing to the difference in location of the cutting edge, the conventional cutting needle tends to create a larger hole with each suture pass than does a reverse cutting needle. A spatula needle has a cutting edge on its sides, parallel to the tissue, but is flat on its top and bottom surfaces, making it ideal for lamellar passes, such as when reattaching the levator aponeurosis to the tarsal plate in an external levator advancement procedure.

Suture materials can be differentiated according to the following characteristics:

Absorbable sutures can be made of natural or synthetic materials and will degrade in tissue over time, whereas nonabsorbable sutures are made with nonbiodegradable materials and are designed to be permanent. Because of the biodegradation process, absorbable sutures tend to be more inflammatory than do nonabsorbable sutures. Absorbable sutures commonly used in oculoplastic surgery include gut (fast-absorbing gut, plain gut, and chromic gut), Vicryl (polyglactin 910), Monocryl (poliglecaprone 25), and PDS (polydioxanone). Selection of absorbable suture depends on retention of suture strength and time to complete biodegradation. Nonabsorbable sutures include silk, nylon, Prolene (polypropylene), Dacron or Mersilene (polyethylene terephthalate), and Gore-Tex (expanded polytetrafluoroethylene). Gut and silk are derived from natural materials, whereas Vicryl, Monocryl, PDS, nylon, Prolene, Dacron/Mersilene, and Gore-Tex are made of synthetic materials.

A monofilament suture is made of a single strand of suture material, whereas multifilament or braided sutures are composed of braided strands of suture material. In general, multifilament sutures have a higher coefficient of friction and are therefore easier to handle and provide greater knot security than do monofilament sutures, which pass more easily through tissue but also unravel more quickly because of low pliability and memory. Because of the braided nature of multifilament sutures, wound infection risk is greater with this suture type. Monofilament sutures include nylon, Prolene, Monocryl, PDS, and Gore-Tex. Braided sutures include Vicryl, silk, Dacron, and Dacron/Mersilene. Gut sutures are technically multifilament sutures of highly purified collagen that are spun, braided, dried, ground, and then polished to achieve a more monofilament-like character (Figure 1.2).